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S 2066APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING.. ha.EcTRICAL PUtl I N O -6 a� BUILDINGDIVISION APPLICATIONMERMI'I• PLUMBING.MECHANICALJ �y 1 40 (/ S Olin ! 10// f n��j ❑ consultant Fecs Paid 6y Applicant (Initial) LICENSED CONTRACTOR'S DECLARATION QTY I nort by off. arm I wt licensed under provisions of Chapter 9 (commencing with Semina a"Rua/f+tD'�ivisio�n J33 at the Bo,ho,dand Profe.•simtasa C�le,vnd m\I'Aactisand m\'Aaceis in full force snit effy(_Ss/� J' J LicenseC �( S.—Lien Dote Co A HITECPS ❑F.CLlif,mc0N 1 understand my plans shall be used as public records Licensed Professional OWNER-BUILDFR DECLARATION 1 hereby union that am exempt from the Contracmr's License Law for the fallowing reason. (Section 7031.5, Ilu.Qness mad Professions Code: Any city or mum, which rotor. a perms In construct, alma improve, demolish, or repair any suucmre prior rat its issuance, oho requires the applicant for such small it, Tile a signed statement that he is licensed pursuant to the provisions of the Contractors License law (Chapter 9 ("'Indicating with Section )(MVI) of Do sloa3 of the Business and profession, Code) or ,In., he is exempt therefrom nM the basis far the alleged exemption. Any vinlation of Section 7031.5 by any applicant for a pemtit subjects the applicant to v civil sedulity of nut snore than five hundred out].. ($500). 1, as owner of the propenyl nr my employees with wages with eir snit Cnmpcnsmion, will do the work, odd the.arveure E not intended araRered lmsale (Se<. 7044, Business .ad Professions Code: The Contmemr:v License Law docs nm apply m an uwoer of prapeny who builds or impravw thereon, and who does such work himself m through his own employees, provided thin such improvnnenrs not, not intended or offered for sae. It, however, the building or improvement is sold within ono year of completion, the wner-builder will have the burden of proving that he did not build or improve for pur- pose of sale.). 1. as owner of the propenyl an exclusively contracting with licensed "mate a s to oalition the project (Sec 7044, Btninexa and Professions CAc:)The Contrae(,,'s Li - se law does not apply man owner of property who builds or improves Inc.., and QTY. who contracts mr such projects with a mntrac ods) accred pursuant m the Conuucmis License Law. ❑ I am exempt under Sm. . B & P C For 'his reason owner Dale WORKER'S COMPENSATION DF.CLARXHON I hereby affirm under penalty of perjury one of the following declaration%: ❑ I have and will maidame.Cmilhane of Comcnt mself-insure rot Worker's Compcm smion, as provide) for by Section 370 of the Lahr Cade, for the peGommnec of the worIF for which this prmit is issued. ❑ 1 haveand will maintain Worker's Compensation Inwreace, m required by Section 370 of the Labor Crile, for the performance of the work for which this permit is foaled. (ELECTRIC PERMIT PIERMU ISSUANCE APPLIANCES - REMDEN'TIAL PANELS UP TO 200 AMPS SIGNS ELECTRICAL ° �-7 SPECIAL CIRCLE VMISC. C 'PIMP'. METER ON POLE INST. ("bisection need not be completed ifthe permit is fiance hundmd dollars ($100) or less.) POWER DEVICES PLUMB ❑C SWIMMING POOL ELECTRIC 2 OUTI.Ii I'S - SWITCHES - FIXTURES I certify that in the performance of the work for which this permit is issued, l shall not mid,any peso in any mannermm, ms ltecomcsohjee m the Workcri Campem ion Laws of California. Dine NOTICE'TOAPPIJCANT:ILaftermakingthisCertificateofExemption,youshould subject m the Worker's Cnngwnswinn provisions of the IaMm Ctxle, you moot bmhwith comply with such pmvisinm nr Nis permit shall be dccrncJ revoked. CONSTRUCTION LENDING AGENCY (hereby uffmnhauhere isaeonmmetiun leading agency for the prchera diecof work for which this fiction is issued (See. 301 Civ. C.) , lenders Name NEW RES] DENT IAL ELECTR SQ ET. v€ ° �-7 ZCp HAZARDOUS MATERIALS DISCLOSURE Will thed,inicant oa Tumebulldmilecetpont store mhanllehaeaNnusmmerm BUILDING PERMIT INFO ("bisection need not be completed ifthe permit is fiance hundmd dollars ($100) or less.) BLDG EL[ ❑, PLUMB ❑C SIEW[;R- SAN] FARY-STORM EA. 20 FT. FEB JOB DESCRIPTION RF ID[ES.L N11A : ❑SFDWL ❑ KITCHEN REMODEL ❑ AUDI TION C1 PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCTURAL MODIFICATION [I INTERIOR ❑ CHIMNEY R17PAIR IMPROVEMEM' C]SWIMMING POOLS ❑ HATH REMODELfREPAIR ❑ DEMOLITION ❑ OTHER I certify that in the performance of the work for which this permit is issued, l shall not mid,any peso in any mannermm, ms ltecomcsohjee m the Workcri Campem ion Laws of California. Dine NOTICE'TOAPPIJCANT:ILaftermakingthisCertificateofExemption,youshould subject m the Worker's Cnngwnswinn provisions of the IaMm Ctxle, you moot bmhwith comply with such pmvisinm nr Nis permit shall be dccrncJ revoked. CONSTRUCTION LENDING AGENCY (hereby uffmnhauhere isaeonmmetiun leading agency for the prchera diecof work for which this fiction is issued (See. 301 Civ. C.) , lenders Name WATER HEATER WNENTIELEC'Of WATERSYSTEMOREATING TNGr WATER SERVICE (AID Dmc © 0 AIR CONUI'fIONEIt 'TOTAL:lender's COMMERCIAL, , ❑NEWBLDGIADDITION @>IlIf ANT IMPROVEMENT ❑ OTHER ❑DEMOLITION ❑ FOOD SERVICE QTY. MECHANICAI, PERMIT FETE SEISMIC FI: • L a PLUMBING PE FEE PHRM1T ISSUANCE ALTER -DRAIN&VF.NT-WA' .) BACK FLOW PROTECT. DFVIC17 DRAINS - FLOOR, ROOF, AREA, COND. FIXTURES -PER TRA(' GAS -IEA. SYSTEM -1 INC. 4 OUTLETS GAS -EA. SYSTEM -OVER 4 (EA) AREA I $/SQ. Signature of Appliclro/Omucmr Uwe COMPIENSAT(ON INSURANCE GREASIJINOUSTRh WASTE: INTERCEPTOR HAZARDOUS MATERIALS DISCLOSURE Will thed,inicant oa Tumebulldmilecetpont store mhanllehaeaNnusmmerm HEATING UNIT(TO I00.000 BTU) ("bisection need not be completed ifthe permit is fiance hundmd dollars ($100) or less.) GRF,ASIETRAP PLAN HECK P k: SIEW[;R- SAN] FARY-STORM EA. 20 FT. VIENT'ILA'ION PAN (SINGLE RESIDd zu zApplicant aMasmc W L) .the 17- O V W W i.�. V) U Z I certify that in the performance of the work for which this permit is issued, l shall not mid,any peso in any mannermm, ms ltecomcsohjee m the Workcri Campem ion Laws of California. Dine NOTICE'TOAPPIJCANT:ILaftermakingthisCertificateofExemption,youshould subject m the Worker's Cnngwnswinn provisions of the IaMm Ctxle, you moot bmhwith comply with such pmvisinm nr Nis permit shall be dccrncJ revoked. CONSTRUCTION LENDING AGENCY (hereby uffmnhauhere isaeonmmetiun leading agency for the prchera diecof work for which this fiction is issued (See. 301 Civ. C.) , lenders Name WATER HEATER WNENTIELEC'Of WATERSYSTEMOREATING TNGr WATER SERVICE (AID Dmc NEW RESIDENTIAL I'LMIi. SQ. PTI AIR CONUI'fIONEIt 'TOTAL:lender's Address I certify Oct I have road this it,liemlon and state that the shove information is remora. I agree m comply with all city and county ordinances and loam law, relining m hullJlog eondrveinn, anA hereM1y uuthonze mprestnmdves of this city lin enter upon the BUILDING FE QTY. MECHANICAI, PERMIT FETE SEISMIC FI: ire t ecu of (her eat wh'hmas, Wukt lnorm kodumceo-s car, le- PatlRy.� nhove-memioned proper for inspection Purposes . (we) agree to save, Indemnify and keep harmless the City of Cupertino against PERMIT ' ISSUANCE ELEiCTRIC FIEE ALT ER OR ADD TO MUCH. PLUMBING V.12 liabilities, judgments, costs and expenses which may in any wayaccrue against said City In consequence of the granting of mis permit. AIR HANDLING UNIT G 010.000 CFM) MECHANICAL, 'EE APPLICANT UNDERSTANDS AND WILL COMPLY WI'fit ALL NON -POINT SOURCE REGULATIONS. AIR HANDLING UNIT(OVER 11.011)CP14) CONSTRUCTION A AREA I $/SQ. Signature of Appliclro/Omucmr Uwe EXHAUST HOLD OVIDUCT) HOUSING MITIGATION FETE HAZARDOUS MATERIALS DISCLOSURE Will thed,inicant oa Tumebulldmilecetpont store mhanllehaeaNnusmmerm HEATING UNIT(TO I00.000 BTU) as defined by the Calendar, Municipal Code, Chapter 9.12, and the Health end Safety Cale, Section 25532(a)P HESUNG UNIT (OVER 10,00 BTU) VIENT'ILA'ION PAN (SINGLE RESIDd E] Yes PAID Dam Receipt if Will the applicant or furore holding occupant use cyuipmoot art devices which mit hazardous air comaminen¢ as defined by the Bay Arco Air Quality Management BOILER -COMP (3HP OR 100.00) BTU) TOT D,dr CO ❑Yes BOILER-COMP(OVER If)(10TOBTU) AIR CONUI'fIONEIt - DATE ISSUANCE S/ Z the hlosexius vdaLs reyuifetrmdtx under Chapter 6,95 af1he Cali I maenadmm famia Health & Sat ty Code.Seco 25505, 25533 and 25534.1 understand ohm fine NEW RESIDENTIAL MECH. SQ. buildic,1 etc yhaveat/`"�]m,thnt it is my reopen ihili to nobly the re ca tI ire t ecu of (her eat wh'hmas, Wukt lnorm kodumceo-s car, le- PatlRy.� /] TOTAL: MA_z ISSUED BY: /\ I